We may not be ok. Taking care of mental health during Covid-19
There is no doubt that we are all living through one of the most tumultuous periods in modern times with most of us dealing with unprecedented changes to how we live and work as a result of COVID-19.
We wanted to find out how this period has impacted our mental health and how health practitioners can best equip themselves to deal with these emerging health challenges.
So are we ok?
Yes and no.
A recent Monash University study launched to track the mental health effects of the COVID-19 crisis has already shown a significant rise in anxiety and depression in Australians. Researchers surveyed 1,200 Australians about how they were coping during the pandemic. Preliminary results showed a majority of participants registered mild levels of anxiety and depression. A significant number however, about 30% of respondents, showed moderate to high levels. Senior Research Fellow, Carolyn Gurvich, notes "this is the first snapshot of the mental health of Australians during these times".
Researchers also think that whilst anxiety will decline for many as the situation improves, there will be a significant minority who will be affected long term. These people may develop a psychiatric condition and ongoing long term mental health problems as a result of the stress, such as anxiety or depression or even a post traumatic stress disorder.
The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has stated that:
‘The effects of loss of income, lockdown, sudden unemployment and homelessness present new challenges for everybody but particularly people with severe mental illness as they are more likely to have existing physical illnesses and social disadvantage’.
Access to treatment
A crucial aspect to Australians seeking help is that they need to be able to access mental health services. Whilst it is clear there is a need, it is also true to say that many Australians are suffering financial hardship.
Fortunately, the Federal Government has partnered with Beyond Blue to offer additional mental health support during the COVID crisis.
On 13 March the Australian Government introduced MBS telehealth and phone consultation items in direct response to the COVID-19 outbreak. These items allow health professionals to deliver services via videoconference and phone to reduce the risk of transmission of COVID-19. These services can be accessed by all Medicare-eligible Australians.
We spoke to a Sydney Psychiatrist who said: "Interestingly the newly appointed assistant to the Chief Medical Officer is a Psychiatrist. We are all very excited about mental health being prioritised like this by the federal government. But we wish this had all happened a long time ago". She also commented with respect to TeleHealth that "there are some limitations with observations".
It is also particularly important for health professionals to note that a TeleHealth service must only be provided where it is safe and clinically appropriate to do so.
Clearly some types of clinical care are more suited to TeleHealth consultations. Given mental health consultations usually do not require a physical examination they are possibly one of the best suited, but with some qualifications.
What are the challenges for health professionals?
We asked Dr Erika Penney, Clinical psychologist and Lecturer at the University of Technology Sydney who is part of a national university working group on TeleHealth training, for her views. This is what she had to say:
"Preliminary results of large scale studies show there has been a rise in anxiety and depression symptoms in Australians since the beginning of the pandemic. Most psychologists believe that beyond anxiety and depression, we are also likely to see an increase in adjustment disorders and alcohol use disorders as people struggle to cope with the financial, relational, and personal stressors of the pandemic."
So, it is clear that health professionals need to be on alert. Whilst patients will often seek help for a changing mole or back pain, when it comes to mental health patients do not always directly ask for help. Particularly at this time, practitioners need to be on the lookout for signs of mental health issues including anxiety, depression, alcohol abuse and other addictions and refer patients who are struggling with these issues if they are not equipped to deal with them. Busy health professionals often may feel that they don’t have time for these ‘how are you coping?’ type conversations, but they are particularly important right now.
It is also worth noting that health professionals are not immune to suffering from mental health issues, particularly at this challenging time where their workloads and own anxieties about COVID-19 will be increased. Often saying ‘I need help’ is even harder for them.
What about dealing with mental health issues when people do seek help? Are there challenges with properly assessing patients via TeleHealth and videoconferencing platforms?
"It depends" says Dr Penney.
”There is emerging literature that E-Psychology is effective for the treatment of anxiety and depression related disorders. However, I believe it comes down to experience and TeleHealth competence. A psychologist with TeleHealth competence will take time in the first session to assist the client to set up their side of the videoconference effectively, i.e., create good lighting, positioning, troubleshoot connectivity issues.
All of these factors will allow a therapist to better pick up body language, facial cues, mental state information, and to ask more explicitly for feedback from the client. There is an emerging wealth of resources and training that is being delivered at present to help psychologists (and other health professionals) upskill in this area.
There are some presentations that will not adapt as effectively to TeleHealth. For example, TeleHealth may not be appropriate for clients with complex comorbidities or moderate to severe substance or alcohol issues as it does not allow for some physical and visual cues to be observed which may be necessary to complete a thorough Mental State Exam. I believe that the necessity of Telehealth during this pandemic period will benefit TeleHealth service delivery in the long-term by legitimising its use among therapists and increase empirical literature in the area."
Duty of care to patients
So whilst Telehealth for mental health looks promising, health care professionals need to be cognisant of, firstly, which consultations are appropriate for Telehealth and secondly, whether some ‘upskilling’ is required to ensure that they use the technology effectively.
Failure to do both of these things could lead to serious consequences.
In Hunter and New England Local Health District v McKenna, a patient with a long history of paranoid schizophrenia was involuntary admitted and detained under the Mental Health Act at the relevant hospital. The patient was discharged the following day to drive himself to Victoria where he was to receive continuing medical treatment. After assessment he was released but tragically killed a companion on route and later took his own life.
The District Court found that the hospital and its psychiatrist had failed to exercise reasonable professional care and skill in discharging the patient. Although the High Court ultimately overturned the decision, this was not on the basis that the hospital and psychiatrist did not breach their duty of care, but rather that they did not owe the alleged duty of care to the third party because it was inconsistent with the statutory obligations under the Mental Health Act.
Health professionals treating patients for mental illness have a duty of care to ensure that the treatment provided is reasonable in all of the circumstances. During Covid-19, as discussed, this may pose additional challenges.
- Practitioners need to be alert for signs of mental health issues. ‘Are you ok? How are you coping?’ type questions are even more important at this time.
- Telehealth can be an effective tool for medical consultations, including for mental health issues, but it is not appropriate in every case.
- If you are using Telehealth give some thought to whether you need to upskill. Seek extra training if required.
- Health professionals have a duty to take reasonable care when assessing and treating patients. The consequences of not doing so are potentially life threatening.
- Put your oxygen mask on first. If you are a health professional and are struggling with your own mental health, ensure you seek help.
References and Resources
Psychiatrists need more changes to address COVID-19 challenges (30 March 2020), RANZCP [Link]
How are you? Living with COVID-19 restrictions in Australia (08 April 2020), Monash University [Link]
Hunter and New England Local Health District case (31 January 2014), [Link]
Mental Health responses to COVID-19 (Explanatory Note), Monash University [Link]
Beyond Blue [Link]